Wednesday, July 19, 2017

Reading :: Rehabilitation of Hand Function

Rehabilitation of hand function
By A.N. Leont'ev and A.V. Zaporozhet͡s

What does hand rehabilitation have to do with psychology? More than I expected. In this book (published in Russian in 1945 and in English in 1960), the authors recount experiments in hand rehabilitation from the perspective of Soviet psychology. And in the process, they lay down markers for what would become the dominant framework for Soviet psychology, activity theory.

Let's put this book in context. Leontiev had worked under Vygotsky in the early 1930s, but then took a job at Kharkov along with other members of the Vygotsky-Luria network. Throughout the early 1930s, Leontiev and Vygotsky differed in their ideas of how Soviet psychology should develop: Vygotsky thought that the root phenomenon to study was word meaning or sense, while Leontiev argued that the root phenomenon was actually labor. Vygotsky died in 1934, and the Vygotsky-Luria network (the "cultural-historical school") came under Stalinist attack in 1936-1937 for being insufficiently adherent to the party line. Leontiev's angle of focusing on labor was easier to defend. In 1940, Leontiev defended his dissertation and in his article "The Genesis of Activity," he laid the tenets for activity theory. (He has been accused of lifting these tenets from Rubinshtein, who sat on his committee.)

When Nazi Germany violated its nonaggression pact with the USSR in June 1941, the Soviet Union moved to a war footing. On February 5, 1943, the USSR established a system of rehabilitation hospitals—and, according to the foreword of this book, by Col.-General E. Smirnov, "it was forbidden to discharge officers and men who were capable of rehabilitation" (p.ix). Luria and Leontiev were assigned to head two of these rehabilitation hospitals.

The book at hand was written based on two research cycles, in 1943 and 1944, focusing on rehabilitation of hand function. Both involved Zaporozhets directly, while Leontiev supervised as scientific director; others were involved, including Gal'perin (first cycle) and Rubinshtein (second cycle) (p.xiii). Zaporozhets wrote Ch.4-9, while Leontiev wrote Ch.1-3 and 10.

In Ch.1, Leontiev sets out the task at hand (no pun intended). He begins by noting that people with restricted movements will perform differently depending on the conditions: telling them to "raise your arm as high as you can" gives poorer results when their eyes are closed compared to when they have their eyes open and are against a ruled screen—and the results are even better when they are asked to "take this object" (p.5). Beginning with the basics of activity theory—actions, motives, object, and activity—Leontiev argues that the differences in performance have to do with the meaning of the action. That is, the "same" action will be invested with a different attitude and orientation depending on the framing activity (p.14). Specifically, the person being rehabilitated may integrate the action into an "activity of self-defence" or "an activity with a difficult motive" (p.14). (In a footnote: "The term 'object' is used here, of course, in its widest sense meaning everything towards which the action is directed" (p.14)).

And this is why hand rehabilitation comes under the heading of psychology. "The character of a movement is determined not by its own motor task and not by the original orientation of the patients' own personality but by the concrete relationship of the one to the other in the given action" (p.16, his emphasis). This insight leads Leontiev to developing occupational therapy. OT already existed before the Soviets got to it, of course, but it had two virtues. First, it got results. Second, it fit the Soviet focus—and specifically Leontiev's focus—on labor. In later chapters, we'll see how this focus on labor plays out.

In Ch.2, Leontiev examines "the co-ordination of deranged movement" (p.17). He argues, following Anokhin and Sherrington, that in trauma such as gunshot wounds, the motor experience is disorganized, and "even when there is complete anatomical preservation of the central and peripheral system, the co-ordination of the movement may be disturbed to some degree" (p.18). Thus rehabilitation should first focus on restoring coordination (p.18). To improve coordination, the researchers used a kymograph (crediting Luria's work with the combined motor method) to provide feedback to patients as they undertook tasks with the uninjured and injured limbs (p.19; the method is quite vague). When patients had this visual feedback, they were able to smooth out their movements in moments (p.21). The task had been reorganized around different stimuli. (I was reminded of the work Leontiev later published in Problems of the Development of Mind in which he supposedly trained people to detect light with their hands—work that A.A. Leontiev later characterized as parapsychology.) The researchers found that the degree of discoordination was not directly correlated to the range of movement (p.26).

Just a note here. Leontiev's experiments (well, the ones he supervised) were not as elegant and clean as Vygotsky's or Luria's. They involved elaborate mechanisms, sketchy statistics, and in places, endless case studies.

Also in this chapter, Leontiev reports on rehabilitation after Krukenberg's operation — an operation for someone whose hand has to be amputated. Essentially, the radius and ulna are separated and the Pronator teres muscle is wrapped around both, allowing the patient to use the two bones as an elongated pincer. Obviously, this operation requires the patient to substantially reconstruct both motor and sensory impulses. In their experiments, the research team concluded that this reconstruction does not simply involve elementary sensation — untrained patients couldn't tell if they were feeling a cube or a cylinder, while trained patients could. (Notice the implications for applying Lenin's reflection theory—you can see them in Leontiev's application.)

Moving on. In Ch.4, Zaporohets discusses "the problem of motor organization and the restoration of movement" (p.63). Here, he argues that trauma leads to a new functional system to protect the injured organ. This functional system should be temporary, but can become fixed.

Interestingly, Zaporozhets emphasizes the practical importance of the work, especially in its aims of putting people back to work (p.64)—the theme of labor as well as the practicality that characterized Stalinist science. In a later chapter, Zaporozhets lauds "the general tonic and encouraging power of rational work activity" in comparison to gymnastic movements and occupational therapy meant to rehabilitate limbs, but without a framing activity (p.146). He quotes Luria along these lines as well (p.148), and he notes that the motivation of activity has a large impact on outcomes—"casual and meaningless orders" can have a "chilling effect" on recovery, while "more consequential and complicated tasks" can accelerate it (p.149).

Leontiev and Zaporozhets, then, wanted to put the occupation back into occupational therapy. One can see how this line of research would be welcome to the overtaxed war leadership of the USSR: not only can the wounded be put back to work, it was good for them! They even give the example of dispirited patients reviving when they were given the meaningful task of manufacturing "window frames and furniture to replace that destroyed by the Germans at Stalingrad" (p.150). Labor, which had created humanity, could also rehabilitate it.

Interestingly, some occupational therapists have also explored this link, although I haven't had the chance to read that literature.

In any case, I found the book interesting in terms of understanding what Leontiev was up to during the war years and how that experience bore on his development of activity theory. For activity theorists not working in OT, I think the book is primarily interesting for historical purposes, but it's still interesting!

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